Provider Demographics
NPI:1659784825
Name:MICKELSON, RYAN (RPH)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:MICKELSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1018 BARTRAM LN
Mailing Address - Street 2:
Mailing Address - City:QUAKERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18951-5013
Mailing Address - Country:US
Mailing Address - Phone:610-762-2184
Mailing Address - Fax:
Practice Address - Street 1:5911 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-1642
Practice Address - Country:US
Practice Address - Phone:215-482-1992
Practice Address - Fax:215-482-9146
Is Sole Proprietor?:No
Enumeration Date:2014-06-05
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP445273183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist